Little Leaguer's Shoulder

Above are MRI images of a 13 year old male baseball pitcher. They are a coronal proton-density (left) and a T2-weighted images displaying a widening of the lateral humeral growth plate.

Little Leaguer's Shoulder is a sports injury occurring from overuse of the joint. The average age for this condition is 14 years old. The most common symptom is pain in the proximal humerus during pitching.

Treatment of this condition includes refraining from pitching for at least three months followed by gradual return to pitching once the shoulder is asymptomatic.

If a patient does not allow the shoulder to heal and the growth plate remains damaged, the result can be a delay in growth in that area.

Acetabulum Fractures

The above image is a surface-rendering 3D CT scan view laterally with the right hemipelvis and left femur removed demonstrating a transverse fracture as well as a displaced and comminuted posterior wall fracture fragment.

Fractures of the acetabulum often occur in automobile or motorcycle accidents, falls, or industrial accidents, when a strong force pushes the head of the femur through the acetabulum.

When these fractures occur they disrupt the smooth surface of the hip joint as well as the fit of the femoral head into the acetabulum and usually require surgery to repair.

The surgical procedure will often include screws and or plates fixated to the damaged areas to hold the fragments in position for healing. Surgical complications can include wound infection and nerve damage, however they are rare. Post operative patients will remain in the hospital to be monitored for pain, infection, and deep vein thrombosis which could lead to a pulmonary embolism.

Fatty Infiltration of the Liver

Fatty infiltration of the liver, also known as fatty liver, is an accumulation of fat in the liver cells. It is not certain how fatty liver occurs but could possibly be fat that is transported from other parts of the body into the liver.

Causes and higher incidence of fatty liver can include heavy alcohol consumption, extreme weight gain, diabetes mellitus, tuberculosis, gastric bypass surgery, use of corticosteroids.

Fatty liver can be diagnosed by the presence of an enlarged liver, elevated liver enzymes, biopsy of the liver, and imaging studies including ultrasound and CT.

On ultrasound images a fatty liver will appear bright in a ripple pattern. CT studies of the liver will present less dense than a normal liver when fatty liver occurs.

Simple fatty liver is not associated with other liver abnormalities however individuals who have fatty liver due to heavy alcohol consumption and continue to drink excessively can result with alcoholic hepatitis or alcoholic cirrhosis.

Fatty liver can occur in patients that do not drink excessively as well. Patients that are at a higher risk for developing fatty liver without excessive drinking include middle aged, significantly overweight, and diabetic individual. These individuals that have a fatty liver the liver can progress to the development of nonalcoholic steatohepatitis (NASH) or steatonecrosis or necrosis. It is possible that between 20-40% of grossly overweight individuals will develop NASH.

Treatment for fatty liver is related to it's cause. Obese individuals will benefit with weight loss. Heavy drinkers will benefit from discontinuing alcohol consumption. Patients with diabetes mellitus can benefit from controlling the diabetes with diet, drugs or insulin.

Mediastinal Teratoma

The above images are a PA Chest X-Ray and a CT Scan of the of the Chest revealing a Mediastinal Teratoma.

A teratoma is tumor consisting of different types of tissue, as of skin, hair, and muscle, caused by the development of independent germ or reproductive cells.

Mediastinal teratomas account for 7% of all teratomas. The mature type of these are benign and do not have potential to metastasize. These can be found in all age groups however they are most common in adults 20-40 years of age.

They are often asymptomatic. If symptoms due occur, they can include chest pain, cough, difficulty breathing, or symptoms similar to pneumonitis.

The treatment for mediastinal teratomas is typically just surgical removal of the cyst. The surgical procedure is the most often cause of complications.

Carotid Body Tumor

This image is a contrast-enhanced T1-weighted MRI of a right carotid body tumor overlying the right carotid bifucation.

The tumor is considered a glomus tumor which are part of the extra-adrenal neuroendocrine system. Glomus tumors most oftenly occur in the inner ear or the temporal bone. They are slow growing and not usually fatal.

Patients with the carotid body type of glomus tumor usually have symptoms such as hoarseness, dysphagia, vertigo, or paresis. They may present with a mobile, non tender lateral neck mass. They are believed to be caused by an overresponse to a change in the body's homeostasis.

CT with contrast, MRI with contrast, and angiography are best for diagnosing. Surgery is the preferred treatment. Patients that are not able to tolarate surgery may undergo radiation therapy or embolization. Embolization can be done prior to surgery because of the vascular nature of the tumors.

Pleomorphic Adenoma

This image is a coronal fat saturated T2-weighted MR image of a patient with a Pleomorphic adenoma. The mass seen involves the deep lobe of the parietal gland.

Pleomorphic adenoma is the most common type of benign salivary gland tumor. These are not typically life threatening however, surgical removal is recommended. Patients do not usually complain of symptoms. They are usually found during routine physical exams or palpated by the patient. CT or MRI studies are done to determine the proximity of the mass to the patient's facial nerve.

Hydrocephalus in Achondroplasia Patients

Achondroplasia is the cause of the most common type of dwarfism and is characterized by abnormally short stature with short arms and legs as well as an enlarged head. It is suggested that hydrocephalus in patients is related to stenosis of the sigmoid sinus. This results in a rise in intracranial venous pressure. The increased venous pressure impairs the absorption of cerebrospinal fluid. The build up of CSF in the brain results in hydrocephalus. This can be seen on MR venography.

Chronic Sinusitis

Chronic Sinusitis is defined as a sinus infection lasting longer than six to eight weeks. An infection lasting less than six to eight weeks is considered acute.

The factors involved in Chronic Sinusitis are:
Structural Obstructions
Allergies
Fungal Infections
Deviated Septum
Nasal Polyposis

The common symptoms of Chronic Sinusitis are:
Sinus Pressure
Pain with Nasal Drainage
Nasal Obstruction
Congestion
Headaches

Patients are clinically evaluated for their symptoms for diagnosis. Along with a clinical evaluation a CT of the sinuses, nasal endoscopic and rhinoscopic evaluations are used to diagnose Chronic Sinusitis. When diagnosing Chronic Sinusitis with a CT exam, the clinician is looking at the osteomeatal complex, which is the area where all of the sinuses drain into the nasal cavity. An obstruction in this area is a souce of recurrent and chronic sinus issues. Abnormal scans will show sinuses filled with fluid or thickened mucous membranes.

Treatments of Chronic Sinusitis include:
Nasal Rinses with Antibiotics
Nasal Steroid Sprays
Oral Steroids
Endoscopic Sinus Surgery

With the endoscopic sinus surgery the abnormal obstructive tissues are removed. Sometimes a sinus shaver is used which precisely removes redundant mucosa and thin bones causing obstructions.

Patients outlook after surgery most patients experience easier nasal breathing, a reduced number and frequency of sinus issues, and sinus related headaches improves.

These images came from facialbeauty.com and demonstrate coronal CT images before and after sinus surgery.

Orbital Cellulitis

Orbital cellulitis is an infection of the soft tissues of the orbit. The most common cause is the spread of an infection of the ethmoid sinuses. However, it can also occur as a result of direct infection cause by orbital trauma or surgery. Bacteria in the blood can also spread and cause optical cellulitis. The first picture above is of a patient with optical cellulitis of the left eye. (emedicine.com) The second image is an axial slice CT image of a patient with optical cellulitis. (Also from emedicine.com) This infection is most common in winter due to the increase in sinusitis. Children are more likely than adults to be affected. Some symptoms include lid edema, orbital pain, fever, headache, decreased vision, increased intra-ocular pressure and inability to open the eye.

To diagnose orbital cellulitis lab test are done as well as imaging studies. Lab tests include CBC, blood cultures and smear for Gram stain and culture of nasal discharge. A high resolution CT scan with pre and post contrast images are used with axial and coronal slices.

Treatment for orbital cellulitis is antibiotics for the infection, diuretics for increased intra-ocular pressure, nasal decongestant if cellulitis is secondary to sinusitis, and an antifungal if the cellulitis is attributed to a fungus.

Craniopharyngioma

Craniopharyngiomas are tumors in the brain located at the base of the skull near the pituitary gland. Most craniopharyngiomas are benign tumors. They account for between 2%-4% of adult and between 5%-13% of childhood primary brain tumors. Patients with these tumors don't usually have symptoms until the tumor grows and pushes against the optic nerve, pituitary gland or the brain. Symptoms can include headache, nausea, vomiting, vision problems, balance issues, difficulty speaking, confusion, seizures, hearing difficulties, and hormonal disorders. To diagnose craniopharyngioma doctors can evaluate the patient clinically by testing their hearing, vision, balance, coordination, reflexes and hormone levels. Imaging studies can be used to confirm clinical evaluation. MRI would show good soft tissue contrast and is the imaging modality of choice. Other imaging could include CT, Angiogram, MRS, SPECT, and PET. Treatments for craniopharyngioma, given separate or together, can give patients a high rate of long term survival. Surgery, external radiation, stereotactic radiosurgery, and intracavity irradiation, are included in the therapies along with the occasional use of chemotherapy.

The images above are a sagittal T1 weighted MRI image on the left and an axial CT scan on the right, both showing a craniopharyngioma.

Bell's Palsy

Bell's Palsy is caused by trauma to the cranial nerve 7 or the facial nerve. The trauma or damage many scientists think is caused from viral menningitis or herpes simplex virus 1. The facial nerve swells and becomes inflammed. Paralysis of the facial muscules result. Many patients experience symptoms that progress quickly. The symptoms include eye and corner of the mouth drooping, tingling around lips, drooling, and dry eye and/or mouth. The majority of patient's with Bell's Palsy are affected unilaterally, bilateral facial paralisis caused by Bell's Palsy is rare. Some populations are more likely to develop Bell's Palsy. They include diabetics, pregnant women in their third trimester, and individuals with a weakend immune system. The diagonsis is usually found in a clinical examination. However, MRI may be used. In a T1 weighted scan with gadolinium the inflamed nerve can be seen. In the image above, the patient has a right sided inflamed facial nerve. Anti-viral and anti-inflamatory medications can be used to treat Bell's Palsy.

Periventricular Leukomalacia

Periventricular Leukomalacia is the necrosis of the white matter within the brain which is caused by lack of oxygen to the tissue. It can also be cause by a brain hemorrhage that has moved into the brain tissue. In the area where the white matter dies is filled with cerebral spinal fluid. One indicator of PVL on MRI or CT images would be unilateral enlarged ventricles. PVL is a disorder that is mostly prevalent in premature babies born 30 weeks gestational age or earlier with immature lungs that need support from a mechanical ventilator. It is estimated that between 4-26% of premature infants will develop PVL.The exact cause of PVL is unknown and patients do not usually show symptoms. If they do show symptoms, they can include apnea and bradycardia. Newborn with PVL are at a much higher risk of develop Cerebral Palsy. The images below are MRI images of an eighteen month old baby with PVL. MRI is not used to diagnose PVL however, it is useful to follow up with previously diagnosed patients or older patients who have gone undiagnosed. Ultrasound is the modality used for initial evaluation.

www.emedicine.com/ped/topic1773.htm 1/27/2008